Negotiating with Managed Negotiating with Managed Care OrganizationsCare Organizations

Checklist for Negotiating a Checklist for Negotiating a Managed Care ContractManaged Care Contract

Checklist for Negotiating a Checklist for Negotiating a Managed Care ContractManaged Care Contract

• Know your costs

• Know your capacity

• Define your competitive advantages

• Know your market & define it for each MCO

• Understand the requirements & standards of each MCO

Checklist for Negotiating a Checklist for Negotiating a Managed Care ContractManaged Care Contract

Checklist for Negotiating a Checklist for Negotiating a Managed Care ContractManaged Care Contract

• Formulate each contract in terms of definitive levels of service

• Maintain patient opinion data regarding the services your organization provides

• Learn the level of ethical commitment of each MCO with which you are negotiating

Checklist for Negotiating a Checklist for Negotiating a Managed Care ContractManaged Care Contract

Checklist for Negotiating a Checklist for Negotiating a Managed Care ContractManaged Care Contract

• Have factual data in hand at the time of your first meeting with the MCO

• Assure that your organization establishes the precedent(s) for subsequent negotiations

Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)

Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)

• Registered• Board members - who & how elected• B.M. specialties - references• Employer groups - can we contact• Number of counties in the state & # of states• Share types of contracts• MCO carry professional liability for providers• Require providers carry professional liability

insurance - how much• Insurance products of MCO valid & legal

Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)

Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)

• UR/QA activities• MCO litigation history• MCO investigated• Blank spaces in contracts - explain• Termination• Termination notice requirements• Documents not reviewed but referenced in

agreement• Mutual hold harmless agreement• Exclusive contracts

Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)

Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)

• Restrict referrals• Unilateral amendment of contract• Contract clauses & state law• Individual physician agreements - even in

groups• Arbitration requirements & effect on

professional liability coverage• Termination impact on doctor-patient

relationship• Confidentiality proprietary information

Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)

Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)

• Cost effective & quality services• Oral representations• Limits on physician’s professional judgment• Time limit claims submission• Timing guarantee claims payment• Interest payment & delayed reimbursement• Verify eligibility• Contract identification of non-covered services• Patient liability for payment of non-covered

services

Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)

Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)

• Use physician names on brochures• Prior authorization• Modify office procedures• Provision of services after contract is terminated• Change of fee schedule by MCO• Substitute physician when away• Unspecified medical policies• Unilateral alteration of standards of care• Qualifications referral physicians

Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)

Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)

• Exclusion of specific specialty services• Gatekeeper• Indemnification provisions - difference between

hold harmless & indemnification provisions• Contract interfere with sound judgment• Assumption of liability for payments after patient

terminates without notifying provider• Contract renewed automatically• Underwriters length of time with company• Can practice limit participation of new members

Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)

Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)

• NCQA accreditation status• Reinsurance provided for catastrophes - specific

with aggregate

Negotiating Posture & Negotiating Posture & TacticsTactics

Negotiating PostureNegotiating PostureNegotiating PostureNegotiating Posture

• Be organized–Spokesperson

• Be confident–Being persuasive vs. first being

persuaded

• Be prepared–Advance preparation

–Rehearsal

–Thinking on your feet

Negotiating PostureNegotiating PostureNegotiating PostureNegotiating Posture

• Be ambitious–Person with higher expectations wins

• Be determined–Must ask to get

• Be positive–Confidence shows

–So does haughtiness & rudeness

Negotiating PostureNegotiating PostureNegotiating PostureNegotiating Posture

• Be cautious–Opponent may read same things you do

• Be courteous–No bad manners or personal attacks

• Be reasonable–Don’t be stubborn

–Deadlocks come from 2 people disagreeing• Mostly unnecessary

Negotiating PostureNegotiating PostureNegotiating PostureNegotiating Posture

• Don’t assume–Everything is open to negotiation

• Don’t annoy–Learn first names

• Don’t posture– Impressing others & showing off

• Don’t let down your guard–“Let’s have dinner”

Negotiating PostureNegotiating PostureNegotiating PostureNegotiating Posture

• Recognize & gracefully accept success when it comes to you

Negotiating TacticsNegotiating TacticsNegotiating TacticsNegotiating Tactics

• Seize the initiative–Choose your issues of import

–Host session if possible• Choose break times • Adjournment• Location of lighting• Home field advantage

Negotiating TacticsNegotiating TacticsNegotiating TacticsNegotiating Tactics

• Emphasize common objectives–Open channels of communication

• Remember the need to save face–One upmanship

• Demonstrate unreasonableness of opponent’s position–No personal attacks

Negotiating TacticsNegotiating TacticsNegotiating TacticsNegotiating Tactics• Use questions & hypotheticals–Use to learn needs & sticking points of

opposition

• Sometimes best to say nothing–Rely on controlled body language

–Brevity is the soul of success

• Never interrupt–Basic courtesy

–Opponent may give useful information

Negotiating TacticsNegotiating TacticsNegotiating TacticsNegotiating Tactics

• Make notes–Gives you time to think

• Thoughtful timing–Wait for right moment to seize the

initiative

• Issues you can concede–Go for “win-win”

• Reduce final agreement to writing–Memo of understanding

Managed Care Facts & Managed Care Facts & FiguresFigures

Facts & FiguresFacts & FiguresFacts & FiguresFacts & Figures

• See overheads